Attitude towards adherence in patients with schizophrenia at discharge

BACKGROUND

Purpose of the present study was to assess the attitude towards adherence at discharge and to verify its predictability using anamnestic and sociodemographic variables, factors influencing clinical treatment as well as the medical treatment applied.

METHODS

Attitude towards adherence was evaluated in 369 inpatients with schizophrenic spectrum disorders within a naturalistic multicenter trial using the Compliance Rating Scale (CRS) by Kemp. Biweekly ratings of the PANSS, UKU and the Subjective Well-being under Neuroleptic Treatment Scale (SWN-K) were applied. Logistic regression and CART analyses were used to determine significant predictor variables for the attitude towards adherence at discharge.

RESULTS

Sixty-seven percent of the patients were rated to have an attitude of active participation and moderate participation (=positive attitude towards adherence) and 33% of the patients to have an attitude of passive acceptance, occasional or permanent reluctance towards treatment as well as refusing treatment (=negative attitude towards adherence). A significant correlation was found between patients with a positive attitude towards adherence and course of all PANSS subscales. Statistical analyses revealed a reduction in PANSS general psychopathology subscore, employment status, greater illness insight and treatment with atypical antipsychotics to be significantly predictive for a positive attitude towards adherence at discharge.

CONCLUSIONS

The importance of an adequate antipsychotic treatment as a precondition for a favourable adherence attitude and the need to incorporate adherence-focused psychotherapy and psychoeducation into daily clinical practice are highlighted.

Abnormal neuroendocrine response to clomipramine in hereditary affective psychosis

BACKGROUND

Blunting of prolactin response after serotonergic stimulation during a major depressive episode has been described by several investigators. In this study, the neuroendocrine responses to clomipramine were assessed in remitted patients suffering from hereditary depression.

METHODS

Twenty remitted patients from 11 large families with multigenerational, multiple cases of major affective disorder (bipolar disorder n=15, recurrent depression n=5, according DSM-IV) and 12 healthy relatives were investigated. After intravenous application of 12.5 mg of the serotonin re-uptake inhibitor clomipramine, serum prolactin and cortisol levels were analysed.

RESULTS

Patients and comparison group did not differ significantly with respect to age, baseline prolactin and cortisol concentrations. A gender effect was found in an exploratory analysis for prolactin but not for cortisol and therefore the data for prolactin were analysed separately. After clomipramine infusion, the increase of cortisol was significantly lower in patients than in the comparison group (P=.046). For prolactin, this effect could be found in the male (P=.012) as well as in the female (P=.007) subsample.

CONCLUSIONS

These results suggest that blunted prolactin and cortisol responses to serotonergic stimulation are characteristic for remitted depressive patients with previous episodes of major affective disorders.

Quality assurance in psychiatry: quality indicators and guideline implementation

In many occasions, routine mental health care does not correspond to the standards that the medical profession itself puts forward. Hope exists to improve the outcome of severe mental illness by improving the quality of mental health care and by implementing evidence-based consensus guidelines. Adherence to guideline recommendations should reduce costly complications and unnecessary procedures. To measure the quality of mental health care and disease outcome reliably and validly, quality indicators have to be available. These indicators of process and outcome quality should be easily measurable with routine data, should have a strong evidence base, and should be able to describe quality aspects across all sectors over the whole disease course. Measurement-based quality improvement will not be successful when it results in overwhelming documentation reducing the time for clinicians for active treatment interventions. To overcome difficulties in the implementation guidelines and to reduce guideline non-adherence, guideline implementation and quality assurance should be embedded in a complex programme consisting of multifaceted interventions using specific psychological methods for implementation, consultation by experts, and reimbursement of documentation efforts. There are a number of challenges to select appropriate quality indicators in order to allow a fair comparison across different approaches of care. Carefully used, the use of quality indicators and improved guideline adherence can address suboptimal clinical outcomes, reduce practice variations, and narrow the gap between optimal and routine care.

Future classification of psychotic disorders

Reclassifying psychotic disorders in the upcoming revisions of the mental disorders section of ICD-10 and DSM-IV will first necessitate the development of a unified and operationalized definition of the term "psychosis". Ideally, such a definition would be harmonized between both groups of diagnostic classification systems and become part of a glossary of terms. Conceptually and based on epidemiological and some genetic work, incorporating dimensional criteria and criteria for prodromal high-risk symptoms may become feasible. Considering the currently available evidence from genetic, neuroimaging and neurophysiological studies, none seems yet sufficiently validated to warrant major changes. However, further research in these areas promises to yield important new insights which may become relevant for the classification of psychotic disorders in the near future. Given the rapid progress in these fields, regular updates of the classification criteria at shorter intervals than in the past may become necessary.

Prevention of rehospitalization in schizophrenia: results of an integrated care project in Germany

The goal of this study was to prevent rehospitalizations and thus to optimize satisfaction with treatment and quality of life in patients suffering by schizophrenia or schizoaffective disorder. A complex intervention with improved cooperation between in- and outpatient services was applied to 46 "high utilizing" patients after discharge from inpatient care during an intervention phase of 6 months. The study was controlled by a matched group of 47 patients receiving treatment as usual. The intervention was based on a computerized decision support module. Eight psychiatrists in private practices were supplied with this software to obtain guideline-based recommendations according to current psychopathology and clinical state. Suggested complex interventions by the software included psychoeducation, social competence group therapy, integrated psychological therapy, computer-based cognitive training, coping skills training, sociotherapy, nursing care, home visits, social-worker care, assistance to family members, and the use of an emergency call-in line. A local hospital project team arranged specifically suggested interventions. We intended to accomplish a reduction of rehospitalization rates by 50% in the intervention group within a 12-month follow-up phase. Satisfaction with treatment, subjective quality of life, and treatment costs in terms of daily inpatient costs were compared between both groups. Moderator variables such as socio-demographical aspects or influences of certain interventions to rehospitalization rate were analyzed. The sample included patients more seriously ill than originally expected. Subjects in the control group (CG) were older (46 years) than those subjects in the intervention group (IG) (40 years). Other sociodemographical aspects (sex, family status, level of education, and number of former hospitalizations) showed no differences between both groups. The rehospitalization rate and the mean length of inpatient treatment were reduced to nearly 50% in the intervention group. The rate of readmissions increased in the control group, leading to a difference of 23% between both groups. The most important factor to favorably influence rehospitalization rates was the participation in coping skills training. There was an increase in patient satisfaction with treatment, while the subjective quality of life remained constant. Since these improvements were accomplished with lower costs (in terms of inpatient care), cost effectiveness was higher in the IG than in the CG. The most important single factor to favorably influence rehospitalization rates was the participation in coping skills training. Only the guideline consistent complex therapies as common intervention caused the significant overall result. Thereby, satisfaction with treatment increased considerably during the 6 months of intervention and remained constant during 12 months of follow up. The model project described is an important step to gain evidence and experience with integrated care for patients with schizophrenia.

Defining and predicting functional outcome in schizophrenia and schizophrenia spectrum disorders

BACKGROUND

To assess criteria and to identify predictive factors for functional outcome. The criteria should cover all domains proposed by the Remission in Schizophrenia Working Group.

METHOD

PANSS ratings were used to evaluate the symptomatic treatment outcome of 262 inpatients with schizophrenia spectrum disorders within a naturalistic multicenter trial. Functional remission was defined as a GAF score >61 (Global Assessment of Functioning Scale), SOFAS score >61 (Social and Occupational Functioning Scale) and a SF-36 mental health subscore >40 (Medical Outcomes Study-Short Form Health Survey). Multivariate logistic regression and CART analyses were used to determine valid clinical and sociodemographic predictors.

RESULTS

In total, 52 patients (20%) fulfilled the criteria for functional remission, 125 patients (48%) achieved symptomatic resolution and when criteria for functional remission and symptomatic resolution were combined 33 patients (13%) achieved complete remission. Younger age, employment, a shorter duration of illness, a shorter length of current episode, less suicidality, and a lower PANSS negative and global subscore at admission were predictive of functional remission. The regression model showed a predictive value of more than 80%.

CONCLUSIONS

A significant association was found between functional remission and symptomatic resolution, indicating reasonable validity of the proposed definition for functional outcome. The revealed predictors for functional treatment outcome emphasize the need for psychosocial and vocational rehabilitation in schizophrenic patients.

Genome-wide association study of alcohol dependence

CONTEXT

Alcohol dependence is a serious and common public health problem. It is well established that genetic factors play a major role in the development of this disorder. Identification of genes that contribute to alcohol dependence will improve our understanding of the mechanisms that underlie this disorder.

OBJECTIVE

To identify susceptibility genes for alcohol dependence through a genome-wide association study (GWAS) and a follow-up study in a population of German male inpatients with an early age at onset.

DESIGN

The GWAS tested 524,396 single-nucleotide polymorphisms (SNPs). All SNPs with P < 10(-4) were subjected to the follow-up study. In addition, nominally significant SNPs from genes that had also shown expression changes in rat brains after long-term alcohol consumption were selected for the follow-up step.

SETTING

Five university hospitals in southern and central Germany.

PARTICIPANTS

The GWAS included 487 male inpatients with alcohol dependence as defined by the DSM-IV and an age at onset younger than 28 years and 1358 population-based control individuals. The follow-up study included 1024 male inpatients and 996 age-matched male controls. All the participants were of German descent.

MAIN OUTCOME MEASURES

Significant association findings in the GWAS and follow-up study with the same alleles.

RESULTS

The GWAS produced 121 SNPs with nominal P < 10(-4). These, together with 19 additional SNPs from homologues of rat genes showing differential expression, were genotyped in the follow-up sample. Fifteen SNPs showed significant association with the same allele as in the GWAS. In the combined analysis, 2 closely linked intergenic SNPs met genome-wide significance (rs7590720, P = 9.72 x 10(-9); rs1344694, P = 1.69 x 10(-8)). They are located on chromosome region 2q35, which has been implicated in linkage studies for alcohol phenotypes. Nine SNPs were located in genes, including the CDH13 and ADH1C genes, that have been reported to be associated with alcohol dependence.

CONCLUSIONS

This is the first GWAS and follow-up study to identify a genome-wide significant association in alcohol dependence. Further independent studies are required to confirm these findings.

Cognitive effects of antipsychotic drugs in first-episode schizophrenia and schizophreniform disorder: a randomized, open-label clinical trial (EUFEST)

OBJECTIVE

Cognitive impairment, manifested as mild to moderate deviations from psychometric norms, is present in many but not all schizophrenia patients. The purpose of the present study was to compare the effect of haloperidol with that of second-generation antipsychotic drugs on the cognitive performance of patients with schizophreniform disorder or first-episode schizophrenia.

METHODS

Subjects were 498 patients with schizophreniform disorder or first-episode schizophrenia who were randomly assigned to open-label haloperidol (1 to 4 mg/day [N=103]), amisulpride (200 to 800 mg/day [N=104]), olanzapine (5 to 20 mg/day [N=105]), quetiapine (200 to 750 mg/day [N=104]), or ziprasidone (40 to 160 mg/day [N=82]). The Rey Auditory Verbal Learning Test, Trail Making Test Part A and Part B, WAIS Digit Symbol Test, and Purdue Pegboard Test were administered at baseline and the 6-month follow-up evaluation.

RESULTS

Compared with scores at baseline, composite cognitive test scores improved for all five treatment groups at the 6-month follow-up evaluation. However, there were no overall differences among the treatment groups. In addition, there was a weak correlation between the degree of cognitive improvement and changes in Positive and Negative Syndrome Scale scores.

CONCLUSION

Treatment with antipsychotic medication is associated with moderate improvement in the cognitive test performance of patients who have schizophreniform disorder or who are in their first episode of schizophrenia. The magnitude of improvement does not differ between treatment with haloperidol and treatment with second-generation antipsychotics. Moreover, cognitive improvement is weakly related to symptom change.

Neuregulin 1 ICE-single nucleotide polymorphism in first episode schizophrenia correlates with cerebral activation in fronto-temporal areas

The Neuregulin (NRG1) gene has been associated with schizophrenia, but its functional implications are largely unknown. Our aim was to assess differential brain activation between patients carrying an at-risk allele on the Neuregulin 1 gene and patients without this genetic risk. Neural signal changes between 14 first episode schizophrenia patients with the at risk allele (SNP8NRG221533) from the Icelandic core haplotype and 14 without were measured with fMRI during a working memory task. Patients without the at risk allele showed greater activations (P < 0.05; corrected) in the left hippocampus, precuneus and cerebellum, as well as the right anterior cingulate. Brain regions previously associated with the pathology of Schizophrenia are differentially affected in those with a genetic at risk status in the NRG1 gene. Heterogeneity of structural and functional measures within patients characterized by clinical phenotypes may be in part due to this genetic variation.

Differential brain activation during facial emotion discrimination in first-episode schizophrenia

BACKGROUND

Aberrant brain activation during facial emotion discrimination has been described in chronic schizophrenia, while little is known about early stages of the illness. The aim of the current study was to investigate valence-specific brain activation of emotion discrimination in first-episode schizophrenia. These patients provide the advantage of lacking the effects of long-term medication and chronic illness course and can hence further enhance the understanding of underlying psychopathological mechanisms.

METHODS

Using event-related fMRI, we investigated 18 first-episode schizophrenia patients and 18 matched healthy subjects during an explicit emotion discrimination task presenting happy, sad and neutral monochromatic facial expressions. A repeated measure analysis of variance (ANOVA) with the factors Group (patients, healthy subjects), Gender and Emotion (happy, sad, neutral) was performed on behavioural and functional data.

RESULTS

Behavioural performance did not differ between groups. Valence-independent hypoactivations in patients were observed for the anterior cingulate and orbitofrontal cortex while hyperactivations emerged in the posterior cingulate and the precuneus. Emotion-specific group differences were revealed in inferior parietal and orbitofrontal brain areas and the hippocampus.

CONCLUSIONS

First-episode schizophrenia already affects areas involved in processing of both, emotions and primary facial information. Our study underlines the role of dysfunctional neural networks as the basis of disturbed social interactions in early schizophrenia.

Guidelines in Consultation-liaison-psychiatry: A Critical Comment (TRAC-NR. 1824 5-17-2008)

Background and aims:

Psychiatric comorbidity of general hospitals inpatients leads to complicated courses of illness and to increased health car costs as compared to patients that suffer from somatic illnesses alone. Such patients are cared for by psychiatric Consultation-Liaison (CL) services. When analyze guidelines that deal with the organization of psychiatric CL-services in USA and the UK, as well with a guideline developed for psychosomatic CL-services in Germany, and an Dutch guideline released in 2008

Methods:

Literature search and review of guidelines.

Results:

Existing guidelines in CL-psychiatry are in part controversial with regard to recommendation for treatments, preferences as to concentrate on clinical, or on organizational issues, and differ even in the grade of evidence given to single topics, such as effectiveness of CL-interventions.

Conclusions:

To improve the efficiency of CL-psychiatry, guidelines might be important, as well for the treatment of psychiatric diseases in general, but even more so for diseases that are frequent in general hospitals such as delirium. However, reliability of guidelines in CL-psychiatry differing among countries should be improved.

How to Develop and Implement Recommended Guidance for European Psychiatry?

One of the concrete projects resolved at the 2nd EPA European Platform of Psychiatrists meeting in Nice 2008 concerns the development and implementation of evidence-based treatment recommendations in psychiatry with an European dimension named "Recommended Guidance". The major objective is to improve quality of mental health care in Europe by providing evidence-based information and advice regarding core clinical questions and to identify and minimize health care gaps. As following steps it was targeted to establish a steering committee, to obtain clinical core priorities by contacting national psychiatric societies, to provide examples of good practice based on existing information, and to develop (first) "recommended guidance" for selected topics as pilot work. To promote this process, information regarding existing guidelines in psychiatry, methodological aspects of their development and evaluation as well as implementation strategies will be provided.

The perspective of German-speaking Countries for the Future work to Develop ICD-11

In the course of the revision of the International Classification of Mental Disorders (currently 10th revision, hence ICD-10), an international scientific partnership network group was founded by the World Health Organisation (Chair: N. Sartorius, Geneva) in order to review the international scientific evidence of putative significance for the revision of ICD-10 in different language areas.

In the course of this project we reviewed several areas of activity that may be of importance for the review process to develop ICD-11. First of all, general questions arise about how a psychiatric classification system should be organized. Will it still depend on classical psychopathological information with additional information from imaging, genetic and laboratory studies, and finally the patient history? An alternative approach is based on functional psychopathology be based on functional neural modules which represent functional activities of the human brain and their disturbances in mental disorders. Another area of debate is whether dimensions rather than categories shall lay a new foundation for the classification of mental disorders. A further issue arises when considering narrative elements of psychiatric history taking. In how far can or should such factors be integrated? All these questions are interwoven with the classical German contributions to psychiatric nosology by Kraepelin and Bleuler, which will be reassessed on the background of these current topics in revising ICD-10.

Neuropsychological impairments predict the clinical course in schizophrenia

To add to the open question whether cognitive impairments predict clinical outcome in schizophrenia, a sample of 125 first episode patients was assessed at the onset and over one year of controlled long-term treatment within a study of the German Research Network on Schizophrenia. No relapse according to predefined criteria occurred within the first year, but a total of 29 patients fulfilled post-hoc criteria of "clinical deterioration". Impairments in cognitive functioning assessed by the Trail-Making Test B at the onset of long-term treatment differentiated between patients with vs. without later clinical deterioration and proved to be a significant predictor of the clinical course in a regression analysis outperforming initial clinical status as predictor. However, low sensitivity (72%) and specificity (51%) limit possibilities of a transfer to individual predictions. As a linear combination of neuropsychological and psychopathological variables obtained highest predictive validity, such a combination may improve the prediction of the course of schizophrenic disorders and may ultimately lead to a more efficient and comprehensive treatment planning.

Social cognition in schizophrenia: an NIMH workshop on definitions, assessment, and research opportunities

Social cognition has become a high priority area for the study of schizophrenia. However, despite developments in this area, progress remains limited by inconsistent terminology and differences in the way social cognition is measured. To address these obstacles, a consensus-building meeting on social cognition in schizophrenia was held at the National Institute of Mental Health in March 2006. Agreement was reached on several points, including definitions of terms, the significance of social cognition for schizophrenia research, and suggestions for future research directions. The importance of translational interdisciplinary research teams was emphasized. The current article presents a summary of these discussions.

Further evidence for a functional role of the glutamate receptor gene GRM3 in schizophrenia

In recent years, evidence has been accumulating indicating a major role of glutamate in the pathogenesis and pathophysiology of schizophrenia. Of particular importance in this regard are the metabotropic glutamate receptors (GRM). Thus, a recently published trial of the amino acid analogue LY2140023, which exerts its effects through the activation of the glutamate receptors GRM3/GRM2, showed an improvement of positive and negative symptoms comparable to treatment with olanzapine. A functional variant of GRM3 has been described which modulates synaptic glutamate levels. We assessed whether this functional variant rs6465084 is related to schizophrenia in a large sample of patients and controls. We found an increased frequency of the A allele (p=0.027) and the AA genotype (p=0.024) in schizophrenia patients. Moreover, in an assessment of schizophrenia endophenotypes, patients of the AA genotype performed poorly in the digit symbol test, a measure of attention (p=0.008). Our results provide further evidence for the potential importance of the glutamate receptor GRM3 in schizophrenia, and indicate that the novel antipsychotic LY2140023 may actually be targeting a pathogenic pathway of schizophrenia.

Standardized remission criteria in schizophrenia: descriptive validity and comparability with previously used outcome measures

INTRODUCTION

Standardized consensus criteria for remission in schizophrenia were recently proposed. As yet, the validity of these criteria and their comparability with previously used outcome measures are unclear.

METHODS

The symptom-severity component of the proposed remission criteria was applied to 288 inpatients who fulfilled the ICD-10 criteria for schizophrenia. Global functioning and psychopathological symptoms were assessed using GAF, PANSS, SANS, HAM-D and CDSS.

RESULTS

When patients with symptom remission at discharge from hospitalization (n=158, 54.9%) were compared to those without symptom remission, significant differences were found with respect to the global functioning (GAF) and all observed psychopathological symptom dimensions. The percentage agreement with previously used outcome measures ranged between 52.6 and 80.0%, the kappa values between 0.120 and 0.594. A moderate accordance (kappa value: 0.495) was found with a Clinical Global Impression (CGI) severity score of three or less.

DISCUSSION

The results indicate a high descriptive validity of the symptom-severity component of the proposed remission definition. However, the new criteria differ partially from previously used outcome measures. This aspect should be considered in the interpretation of clinical trials.

The hippocampus in families with schizophrenia in relation to obstetric complications

BACKGROUND

Hippocampal volume reduction is a well replicated finding in schizophrenia. Evidence indicates a contribution of genetic and environmental factors, especially the influence of obstetric complications to this volume reduction. The aim of this study was to compare hippocampal volume of schizophrenic patients as well as and their relatives with control subjects and to quantify the additional contribution of obstetric complications.

METHODS

T1 weighted MRI brain scans of 50 schizophrenic patients, 88 first-degree relatives and 53 healthy control subjects were used to perform volumetric measurements on the left and right hippocampus. A set of clinical measures including obstetric complications were recorded for all family members.

RESULTS

Numerically our measurements revealed a hippocampal volume reduction in schizophrenic patients (left: -14%, right: -15%) and, although less pronounced, in their unaffected relatives (left: -6%, right: -10%). Noted differences in hippocampal volume between schizophrenic patients and controls were only significant for the left side. Hippocampal volumes of patients and their relatives with obstetric complications were reduced bilaterally.

CONCLUSIONS

Hippocampal volume reduction is present in schizophrenic patients and their first-degree relatives, suggesting an influence of genetic factors. In addition, however, obstetric complications have also been shown to play a major role.

Implementation of a schizophrenia practice guideline: clinical results

BACKGROUND

In mental health care, a range of guidelines with sound methodology is available; however, implementation studies in routine care are scarce.

METHOD

In a controlled before-and-after study design, the pharmacologic part of the German evidence-based schizophrenia guideline was implemented using a quality-circle-based intensive implementation program. 151 adult inpatients with a diagnosis of schizophrenia or schizo-affective disorder (according to ICD-10 criteria) were assessed in 4 psychiatric wards before (N = 77) and after (N = 74) guideline implementation. Treatment process and patient outcome were assessed at admission and discharge using the Positive and Negative Syndrome Scale (PANSS) and predefined process measures. A propensity score model adjusted for baseline psychopathology and sociodemographic variables was used. Data were collected from April to September of 2005 and from January to May of 2006 for the preintervention and postintervention periods, respectively.

RESULTS

After guideline implementation, the rate of antipsychotic monotherapy at discharge increased from 39.5% to 67.6% (p = .021) and the incidence of significant neurologic side effects decreased from 26.3% to 7.0% (p = .038). Antipsychotic dosage and prescriptions of other psychotropic drugs did not change. Although patients in the postintervention group were more severely disturbed at baseline, the reduction in PANSS total score was significantly greater among this group than among the preintervention group (p = .048).

CONCLUSION

After guideline implementation, we observed significantly more antipsychotic monotherapy and a decrease in adverse drug effects. Changing physician behavior and improving process and outcome measures requires intense efforts.

Needs-oriented discharge planning and monitoring for high utilisers of psychiatric services (NODPAM): design and methods

Background

Attempts to reduce high utilisation of psychiatric inpatient care by targeting the critical time of hospital discharge have been rare.

Methods

This paper presents design and methods of the study "Effectiveness and Cost-Effectiveness of Needs-Oriented Discharge Planning and Monitoring for High Utilisers of Psychiatric Services" (NODPAM), a multicentre RCT conducted in five psychiatric hospitals in Germany. Inclusion criteria are receipt of inpatient psychiatric care, adult age, diagnosis of schizophrenia or affective disorder, defined high utilisation of psychiatric care during two years prior to the current admission, and given informed consent. Consecutive recruitment started in April 2006. Since then, during a period of 18 months, comprehensive outcome data of 490 participants is being collected at baseline and during three follow-up measurement points.

The manualised intervention applies principles of needs-led care and focuses on the inpatient-outpatient transition. A trained intervention worker provides two intervention sessions: (a) Discharge planning: Just before discharge with the patient and responsible clinician at the inpatient service; (b) Monitoring: Three months after discharge with the patient and outpatient clinician. A written treatment plan is signed by all participants after each session.

Primary endpoints are whether participants in the intervention group will show fewer hospital days and readmissions to hospital. Secondary endpoints are better compliance with aftercare, better clinical outcome and quality of life, as well as cost-effectiveness and cost-utility.

Discussion

If a needs-oriented discharge planning and monitoring proves to be successful in this RCT, a tool will be at hand to improve patient outcome and reduce costs via harmonising fragmented mental health service provision.

Trial Registration

ISRCTN59603527

Atypical symptoms in hospitalised patients with major depressive episode: frequency, clinical characteristics, and internal validity

OBJECTIVE

The objective was (1) to assess the frequency of atypical depression (AD) in depressed inpatients; (2) to compare clinical features of patients with atypical and nonatypical depression (Non-AD) (3) to evaluate the meaning of single psychopathological symptoms with special respect to mood reactivity.

METHOD

Diagnoses of 1073 inpatients were assessed according to DSM-IV using SCID (Structured Clinical Interview for the DSM-IV) and AMDP (Association for Methodology and Documentation). Diagnosis of atypical depression was defined according to criteria of the DSM-IV specifier for AD. All patients were rated using HAMD-21 (Hamilton Depression Scale).

RESULTS

A high percentage of patients met criteria for AD (15.3%, 95% CI 13.0-17.9%). Women were more likely to suffer from AD (OR=1.54, p=0.037). There were no significant differences between AD and Non-AD patients regarding age, HAMD total baseline score, and diagnosis of any bipolar illness. In terms of psychopathology patients with AD were significantly more likely to suffer from somatic anxiety, somatic symptoms, guilt, genital symptoms, depersonalisation and suspiciousness as defined by HAMD-21 items. Interestingly, mood reactivity was not found to be significantly associated with the presence of two or more additional symptoms of AD.

LIMITATIONS

Results were assessed by a post-hoc analysis, based on prospectively collected data. Compared to other inpatient samples with MDE, prevalence of bipolar disorder was rather low.

CONCLUSION

(1) Frequency of AD may be underestimated, especially in inpatient samples. Further studies of inpatient samples are recommended. (2) Quality of distinct anxiety symptoms may be different in both groups, with AD patients being more likely to suffer from somatic symptoms and somatic anxiety. The presence of suspiciousness and even paranoid phenomena may not exclude a diagnosis of AD, but may be related to rejection sensitivity. (3) The mandatory presence of mood reactivity for the diagnosis of AD needs further consideration, regarding its validity for the concept.